CLINICAL PRACTICE GUIDELINE Wound care...Wound care Page 2 of 21 Obstetrics & Gynaecology See SCGH...

of 21

King Edward Memorial Hospital

Obstetrics & Gynaecology

Contents

Simple dressing .................................................................................... 2

Removal of sutures............................................................................... 2

Removal of staples ............................................................................... 3

Care in the home (Visiting Midwifery Service) .................................... 3

Drains .................................................................................................... 4

Wound drainage systems..................................................................... 4

Pre-vacuumed closed system: Management ...................................... 5

Removal of a drainage tube ................................................................. 6

Removal of a vaginal drain ................................................................... 7

Removal of a vaginal T-Tube ............................................................... 8

Collection of a wound swab ............................................................... 10

Topical negative pressure wound therapy (TNPWT) –single use ... 12

Troubleshooting .................................................................................................... 15

Negative pressure wound therapy (NPWT) (non-topical) ................ 16

Complex wound management: Referral to HITH at SCGH ............... 17

Inpatient referral process ...................................................................................... 18

VMS referral process ............................................................................................ 19

References .......................................................................................... 20

CLINICAL PRACTICE GUIDELINE

Wound care This document should be read in conjunction with this Disclaimer

http://www.kemh.health.wa.gov.au/For-health-professionals/Clinical-guidelines/Disclaimer

Wound care

Page 2 of 21


See SCGH Nursing Practice Guideline No 16 Wound Management for dressings,

skin tear management, suture and staple removal, and negative pressure wound

therapy.

Please note that this guideline is for clinical information only. Information contained

in it regarding contacts and paperwork (e.g. MR numbers) are not applicable for

KEMH.

KEMH Specific:

KEMH uses Wound Assessment and Care Plan (MR263) and do not use

Wound Management plan MR 637

KEMH use MR 260.01 Risk assessment for pressure ulcers in combination

with MR 260.03 Comprehensive skin assessment and do not use MR 856

pressure injury risk and skin integrity management

Dressings as per medical instructions.

For postoperative measures for surgical wounds, see also KEMH Infection

Prevention and Management policy: Prevention of Surgical Site Infections:

Postoperative Measures

Detergent / disinfection wipes are used for cleaning of dressing trolley

Simple dressing Refer to SCGH Nursing Practice Guideline No 16 Wound Management

Removal of sutures Note: Specific instructions from the medical officer must be received before

removing sutures.

In addition to the procedure in SCGH guideline No 16 Wound Management:

Post procedure

Document removal of sutures in

the patient’s medical record.

Document wound healing/status in


MR 249.61 Caesarean Birth Clinical

Pathway or MR 286 Gynaecology

Nursing Observation Chart and MR

250 Integrated Progress Notes.

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/SCGH/SCGH.NPG.Wound_Management.pdfhttps://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/WNHS/WNHS.IC.HAI.SSIs.pdfhttps://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/SCGH/SCGH.NPG.Wound_Management.pdfhttps://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/SCGH/SCGH.NPG.Wound_Management.pdf

Wound care

Page 3 of 21


Removal of staples Note: Specific instructions from the medical officer must be received before

removing staples.

In addition to the procedure in SCGH guideline No 16 Wound Management:

Procedure

Prior to the procedure

Check post op instructions for the

time of staple removal MR 310

caesarean section or MR 315

operation record

Post procedure

Document removal of staples in


Document wound healing/status in


MR 249.61 Caesarean Birth Clinical

Pathway or MR 286 Gynaecology

Nursing Observation Chart and

MR250 Integrated Progress Notes

Care in the home (Visiting Midwifery Service)

Check the VMS summary (referral) for post-operative instructions for the time

of staple removal or contact the ward of discharge.

Ensure patient and staff safety in terms of correct manual handling and

posture within the home environment.

Follow the procedure as documented.

Document the care given and wound healing / status in the patients

Caesarean Birth clinical pathway (MR249.61) or VMS progress notes

(MR255).

If concerned regarding the wound:

Discuss with the VMS Coordinator or a core staff member

Discuss with Obstetric or Gynaecology registrar (via KEMH switchboard)

Arrange review in the Emergency Centre at KEMH (if applicable)

Complete the VMS to EC referral form (MR026) and notify the department

Alternatively, the patient may choose to see her local general practitioner

or present at an Emergency Centre closer to her home.

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/SCGH/SCGH.NPG.Wound_Management.pdf

Wound care

Page 4 of 21


Drains See SCGH Nursing Practice Guideline No 65 Wound Drain Management for drain

dressings, shortening, emptying, suction (e.g. Varivac) and removal of drains.

Please note that this guideline is for clinical information only. Information contained

in it regarding contacts and paperwork (e.g. MR numbers) are not applicable for

KEMH.

KEMH uses

Wound assessment and care plan MR 263

Fluid Balance Chart MR 729

Detergent / disinfection wipes for cleaning of dressing trolley

Wound drainage systems 1. Provide education to the patient regarding mobilising with a drain in-situ. Patient

safety- See Clinical Guideline: O&G: Falls Risk Assessment and Management.

Assessment & documentation

2. Assess and document the type and number of drains, suction, drainage,

volume, colour, and description of drainage:

Sanguineous- bright red;

Serosanguineous / Haemoserous- pink- usually appears a few hours

post-op and decreases over time;

Serous fluid- clear/straw coloured;

Purulent- thick yellow or grey/green, malodorous;

Chyle- cloudy/milky white lymph drainage).

3. Monitor the amount and type of drainage with post-operative observations or

as clinically indicated. Monitor the drainage bottles 4 hourly in the first 24

hours after insertion.1 The frequency of monitoring is adjusted according to

the clinical situation.

Closed vacuum systems should be assessed regularly, with a minimum

of 4 hourly assessments in hospital (PRN & daily in community) for the

presence of continued intended vacuum and volume/ consistency of

fluid drained. Vacuum systems may need to be changed or suction

used to re-establish a vacuum.1

Open drain dressings must be assessed regularly and changed if wet.

It may be necessary to weigh the dressings before and after changing

to accurately assess the amount of drainage. Make note of any signs of

wound infection or maceration, particularly if there is excessive

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/SCGH/SCGH.NPG.Wound_Drain_Management.pdfhttp://kemh.health.wa.gov.au/~/media/Files/Hospitals/WNHS/For%20health%20professionals/Clinical%20guidelines/OG/WNHS.OG.FallsRisksPreventionManagement.pdf

Wound care

Page 5 of 21


drainage fluid making prolonged contact with the surrounding skin.

Document as for Closed Vacuum Drainage.

4. Fluid drainage should be measured and recorded on the 24 hour fluid intake/

output medical record (where applicable) and integrated progress notes. As a

minimum, mark the drain fluid level with a line, date and time at 2400hrs each

day2 or as specified by medical team (e.g. 0700hrs).

5. Excessive drainage must be reported to the medical team.3 Drainage may be

blood stained immediately following surgery, but then becomes serous. Any

blood stained drainage or blood clots may indicate haemorrhage. Document

the amount and colour of any drainage on the MR 286- Gynaecology Nursing

Observation chart or MR 249.61 Caesarean Birth Clinical Pathway. Consider

contacting the medical team.

If the amount is >100mL in 1 hour: Perform vital sign observations,

inform the shift co-ordinator and request medical staff review.

If there is no drainage or the presence of swelling and increased pain:

Perform vital sign observations, assess the wound and drain patency,

and notify the medical staff.

Signs of infection

6. Monitor the wound and drain insertion site for signs of infection (e.g.

inflammation, pain, redness, swelling, heat, discharge) and notify the medical

staff if signs are present.

7. A specimen/swab for culture and sensitivity should be collected from the drain

site if there is presence of purulent discharge or an inflamed site.3 See also

section: Collection of a Wound Swab.

8. All drains should be assessed to ensure they are complete after removal. Any

suspected incomplete drains or missing fragments must be reported to the

medical staff immediately for review.1

9. The removal of drains must be signed off in the operative notes MR 310

Caesarean Section or MR 315 Operation Record.

Pre-vacuumed closed system: Management

Change of unit

The pre-vacuumed units should be changed in these situations:

When the indicator system shows minimum or no vacuum

The bottle is full

The bottle is nearly full at or near 2400 hours.

Wound care

Page 6 of 21


Removal of pre-vacuumed closed system drain

The pre-vacuumed closed system drain is removed at the doctor’s discretion

or according to post-operative orders.

Recording drainage volume closed systems

Drainage amount and type should be recorded on the Fluid balance chart: MR 729

At 2400 hours. Mark the fluid level with a horizontal line using a felt tipped

pen. Note time and date.

When the drainage system is changed. Note the time and date.

On removal.

Removal of a drainage tube

Procedure

1 Prior to the procedure

Confirm written instructions by the medical officer regarding removal of the

drainage tube in the patient medical records.

2 Procedure

If the drain is not easily removed leave it in situ. Notify the nursing Co-

ordinator and medical staff for review.3

2.1 Assess the drain to ensure it is complete.

Report to the medical staff if the drain appears incomplete or has jagged edges.3

If the tip of the drain is required for microbiological investigation, it should be cut

off with sterile scissors and placed in a sterile container to maintain asepsis

3 Document the procedure in the patient’s medical record and on MR325

(Handover to Recovery/Ward)

Documentation should include:

presence of ongoing drainage exudate

volume of drainage (as applicable)

signs of infection at the wound site

3.1 Monitor dressing regularly.

Replace dressings as required.

Report excessive drainage to the medical team.3

Wound care

Page 7 of 21


Removal of a vaginal drain

Aim

To guide the removal of a vaginal drain.

Equipment

Sterile dressing pack

Optional additional equipment – stitch cutter, sterile scissors, and gauze

swabs

Continence sheet

Combine / sanitary pad

PPE- gloves, face mask and protective eyewear

Rubbish receptacle

Ensure dressing trolley is cleaned with hospital grade detergent before and after the

procedure.

Procedure

PROCEDURE


1.1 Confirm written instructions by the medical officer regarding removal of the

vaginal drain in the patient medical record.

1.2 Explain the procedure and obtain verbal consent from the patient.

1.3 Assess patient comfort and analgesia requirements.

Place incontinent sheet under the patient’s buttocks.

1.4 Open and prepare equipment as required.

1.5 Perform hand hygiene.

1.6 Don clean gloves and personal protective equipment.

1.7 Remove dressing and discard.

1.8 Release suction on the drain, if appropriate.

1.9 Perform hand hygiene. Don sterile gloves as required.

2 Procedure

2.1 Cleanse wound site with normal saline as required. Dry.

2.2 Remove the suture if the drain is held in situ with it.

2.3 Maintain gentle traction and ease the drain gently out from the wound.

Wound care

Page 8 of 21


PROCEDURE

2.4 Apply a dressing pad / sanitary pad on the perineum.

2.5 Remove gloves and perform hand hygiene.

3 Post procedure

3.1 Ensure the patient is comfortable.

3.2 Document the procedure on the MR 325 Handover to Recovery/Ward


presence of ongoing drainage exudate


3.3 Monitor vaginal discharge.

Encourage the woman to replace sanitary pads as required.

Report excessive drainage to the medical team.3

Removal of a vaginal T-Tube

Aim

To guide staff with the removal of a vaginal T-Tube.

Equipment

Sterile dressing pack

Stitch cutter

Optional equipment – sponge holding forceps

Gloves

Sanitary pad / combine

Continence sheet (bluey)

Rubbish receptacle

Ensure dressing trolley is cleaned with hospital grade detergent before and after the

procedure.

Wound care

Page 9 of 21


Procedure

PROCEDURE


1.1 Confirm written instructions by the medical team regarding removal of the

vaginal t-tube in the patient medical record.

1.2 Explain the procedure and obtain verbal consent from the patient.

1.3 Assess patient comfort and analgesia requirements.

Place incontinence sheet under the patient’s buttocks.

1.4 Open and prepare equipment as required.

1.5 Perform hand hygiene.

1.6 Don clean gloves and personal protective equipment.

1.7 Remove dressing/pad and discard.

1.8 Release suction on the drain, if appropriate.

1.9 Perform hand hygiene. Don sterile gloves.

2 Procedure

2.1 Remove the suture if the drain is anchored in situ.

2.2 Grasp the drain as close to the visible insertion site as possible and pull

firmly, applying gentle constant force.

2.3 Place a perineal pad or sanitary napkin over the perineum.

2.4 Remove gloves and perform hand hygiene.

3 Post procedure

3.1 Ensure the patient is comfortable.

3.2 Document the procedure in the patient’s medical record.


presence and type of discharge


signs of infection

3.3 Monitor ongoing vaginal discharge.

Encourage the patient to change perineal pad as required.

Encourage the patient to report excessive drainage to nursing/medical

personal.

Wound care

Page 10 of 21


Collection of a wound swab

Purpose

To provide the appropriate interventions for the needs of the individual patient

while reassessing the clinical status of the patient in response to all

interventions and disease processes.

To collect wound exudate for microscopy and culture without contamination

To enable identification of organism(s) causing infections

To enable identification of an antibiotic sensitivity pattern to guide appropriate

treatment.

Key points

1. Wound swabs should be collected when any of the following are present

Local heat; Redness / erythema;

Increased pain or tenderness;

Oedema

Inflammation;

Abscess / pus; Purulent discharge; Malodour

Delayed healing

Discolouration of wound bed

Friable granulation tissue that bleeds easily.

Pocketing / bridging at the base of the wound

Wound breakdown

2. This procedure requires aseptic technique.

3. Local anaesthetic should not be used prior to swab collection.

4. Wound swabs should be collected prior to the patient commencing systemic

antibiotic therapy.

5. The swab must be collected from an area of viable tissue where the clinical signs

of infection are present.

6. The swab should not contain dead tissue or yellow, fibrous slough, pooled

exudate or be taken form the wound dressing.

7. The wound swab should be taken before antiseptic solutions have been used on

the wound.

8. Swabs must be transferred to the laboratory as quickly as possible. Do not place

in a refrigerator prior to transfer, they must remain at room temperature.

9. If the wound swab is from a caesarean section or gynaecology wound, contact

Infection Prevention and Management and complete a surgical site notification slip.

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/WNHS/WNHS.IC.HAI.AsepticTechnique.pdf

Wound care

Page 11 of 21


Procedure

Equipment

70% Alcohol or Detergent wipe (for decontaminating trolley)

Dressing pack; Dressing trolley

Sterile swabbing solution (sodium chloride 0.9% is normally used to clean wounds)

Bag to dispose of used items

Sterile swab stick

Transwab (dual tube with swab stick plus charcoal transport medium)

PPE: Gloves; Plastic apron; Eye protection – risk assess if deemed necessary

Collecting a wound swab

1. Positively identify the patient.

2. Perform hand hygiene.

3. Don gloves. If a dressing is present, perform hand hygiene, remove the old

dressing and repeat hand hygiene.

4. Before collecting a swab remove all excessive debris and dressing product

residue without unduly disturbing the wound surface. This can be achieved by

using a gently stream of sterile 0.9% sodium chloride. Normal saline cleanses

the contaminants without destroying the pathogen.

5. Remove excess saline with a sterile gauze. This exposes the wound to

ensure a good culture is collected

6. Wait for 1 -2 minutes to allow the organisms to rise to the surface of the wound.

7. Exudating wounds – do not pre moisten the swab.

8. Non-exudating wounds – pre moisten the swab with normal saline.

9. If fresh pus or wound fluid is present ensure this collected on the swab.

10. The Levine technique is the preferred method when taking a wound swab. A

swab is rotated over a 1cm2 area of the wound with sufficient pressure to

express fluid from within the wound tissue.

11. Once collected the swab should be placed in the charcoal medium.

12. Correctly label the specimen(s).

13. Ensure the following information is on the request form

Area the swab was collected from.

Patient condition or diagnosis

If the patient is receiving antibiotics.

14. Send the specimen(s) immediately to the lab on the sealed pocket of a

Biohazard bag

15. Complete a Wound Assessment and Care Plan form (MR 263).

Wound care

Page 12 of 21


Topical negative pressure wound therapy

(TNPWT) –single use

Note KEMH uses wound assessment and care plan MR 263 and does not use

NWPT Chart MR 871

For all clinical photography contact page number 3465 between 0800 and

1600hrs Monday to Friday.

NPWT equipment available from CNC ward 6 or via CNS in theatre. KEMH

does not obtain equipment from SCGH Hospital Equipment Service

Aim

To promote wound healing in high risk patients and reduce rates of infection

and wound dehiscence.

Overview description

The application of Topical Negative Pressure Wound Therapy can assist with the

prevention of wound complications in surgical incision sites. Complications include surgical

site infection (SSI), dehiscence and haematoma. Patients regarded as being in the ‘high

risk bundle’4, 5 (see risk factors below) are deemed suitable candidates for this therapy.

Background

NPWT involves applying a vacuum across a wound to improve the wound healing

process and is indicated for use on clean, closed surgical wounds.5-7 It has been

found to reduce the incidence of SSIs in high risk patients through improving blood

flow to the area, reducing haematoma and oedema formation, enhancing the

development of granulation tissue, splinting the wound edges and sealing the wound

from exposure to bacteria.6 Each patient should have a holistic assessment to

identify the suitability for NPWT prior to its application.

NB: Using these dressings on low risk patients has not been shown to improve outcomes.5

Key points 7

1. Dressing lengths of 30cm and 40cm are available. Ensure the wound is entirely

covered by the absorbent island.

2. The system is designed to provide 7 days of therapy7. There are two dressings in

the pack.

3. Each system comes with a patient information booklet. Place a hospital sticker

onto the booklet and ensure it remains with the patient.

4. As the wound is visualised less frequently while the system is in place, ensure to

monitor for signs of infection. These include pyrexia, heat, pain and erythema.

5. If at any time the fixation strips and/or dressing are lifted or removed, the

Wound care

Page 13 of 21


dressing must be replaced.

6. Excessive bleeding is a serious risk associated with suction to wounds. Careful

patient selection is essential.

Indications for TNPWT

This therapy is indicated for clean, closed surgical wounds 5-7 on patients who are

deemed high risk. Higher rates of SSI are associated with but not limited to the

following risk factors:

High BMI >35 4, 6, 8, 9

Diabetes (Type 1, Type 2 & Gestational) 4, 5, 8

History of wound infection or dehiscence 4

Prolonged labour

Rupture of membranes > 6 hours10

Multiple Caesarean Births ≥3 4

Poor skin integrity 4

Smoker and/or IV Drug User5

Pre-operative pyrexia (>38 degrees) 5

Immunocompromised (current infection, neutropenic) 4, 5

Comorbidities i.e. Hypertension, Vascular disease, Cancer 4, 5, 8

Length of procedure exceeding 2 hours8 (>48 minutes for caesarean section)10

It is the responsibility of the surgical team to determine which patients are suitable

for this therapy. Patients are recommended to have this therapy if they have a BMI

>45 or a minimum of three of the above risk factors (KEMH directive) to be

deemed suitable for this dressing post-operatively.

Wounds NOT suitable for the use of NPWT 7

Non enteric, non-explored fistulae to other organs or body cavities.

Necrotic eschar

Confirmed and untreated osteomyelitis

Malignancy in the wound (once any malignancy has been removed its use

may be indicated following discussion with medical staff).

Direct placement of NPWT over exposed blood vessels.

Anastomotic sites.

Pleural, mediastinal or chest tube drainage

Wounds where caution is required using NPWT 7

Enteric fistulae

Active bleeding

Wound care

Page 14 of 21


Patients on anticoagulants

Difficult wound haemostasis

Proximity to blood vessels

Haemoglobinopathy (Sickle Cell)

Abnormal clotting

Underlying structures in the wound e.g. organs and bowel

May be used with surgical drains provided the dressing is not placed over the

tubing where it exits the skin. Any surgical drain should be routed under the

skin away from the edge of the dressing and function independently.

Risks with use 7

Patients must be closely monitored for bleeding. If sudden or increased

bleeding is observed, immediately turn off the negative pressure. Leave the

dressing in place, take appropriate measures to stop bleeding and seek

immediate medical assistance.

The use of anticoagulants does not deem a patient inappropriate for negative

pressure therapy; however haemostasis must be achieved before applying

the dressing. Patients suffering from difficult haemostasis or who are receiving

anticoagulant therapy have an increased risk of bleeding. During therapy,

avoid using haemostatic products that, if disrupted, may increase the risk of

bleeding. Frequent assessment must be maintained and considered

throughout the therapy.

At all times care should be taken to ensure that the pump and tubing does not:

Lie in a position where it could cause pressure damage to the patient.

Trail across the floor where it could present a trip hazard or become

contaminated.

Present a risk of strangulation or a tourniquet to patients.

Rest on or pass over a source of heat.

Become twisted or trapped under clothing or bandages so that the

negative pressure is blocked.

In the event that defibrillation is required, disconnect the pump from the

dressing prior to defibrillation.

MRI is unsafe. Do not take the vacuum unit into the MRI suite.

This therapy is not intended for use on board an aircraft, the batteries should

be removed during air travel.

Although the dressing can be used under clothing and bedding it is important

that occlusive materials (e.g. film dressings) are not applied over the pad area

of the dressing as this will impair the device’s performance.

Wound care

Page 15 of 21


Post-operative care 7, 11

Patients may shower while the dressing is in place. Place the pump into a

water-tight bag or disconnect the pump and ensure the port is pointing

downwards so that water cannot enter the tube. Jets of water and soaking

must be avoided.

Monitor the dressing for loss of negative pressure and high amounts of

exudate.

NPWT can cause discomfort and pain. Analgesia may be required during

therapy and dressing changes.

More frequent dressing changes may be required depending on the level of

exudate, condition of the dressing, wound type and size etc.

The dressing should be inspected every 4 hours for the initial 24 hours post

operatively and then at a minimum of each shift.

The patient should be monitored carefully for any evidence of a sudden

change in blood loss status.

Sudden or abrupt changes in the volume or the colour of the exudate must be

reported to the medical team.

The system is designed to provide 7 days of therapy. There are two dressings

in the pack. The first dressing will be changed at 48 hours (earlier if there is a

high level of exudate) and the wound will be visualised and assessed.

7 days of therapy should be achieved where possible.

If staples/removable sutures are in place, remove the second dressing on day

5 along with the staples/sutures.

Appropriate patient education should be provided prior to discharge. A

detailed booklet is supplied with the dressing; this must be given to the

patient. If this booklet is missing, please contact Theatre or the company

representative.

When the therapy is complete, the dressing can be discarded in general

waste. The batteries must be removed from the pump and disposed of

according to local regulations.

Troubleshooting

A troubleshooting guide can be found inside the dressing box

The patient booklet provides information on post-operative case and what the

coloured lights on the pump display mean.

If education is required in your area or you are seeking brand-specific

information about application, use and troubleshooting please contact the

relevant company Representative.

Wound care

Page 16 of 21


Negative pressure wound therapy (NPWT)

(non-topical) Management of NPWT for an open wound (e.g. dehisced, surgically debridement)

see Application and care of NPWT see SCGH practice guideline No 16 : Wound

management

On discharge with a non-topical NPWT, the patient is referred for ongoing wound

management with HITH at SCGH- see section below.

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/SCGH/SCGH.NPG.Wound_Management.pdfhttps://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/SCGH/SCGH.NPG.Wound_Management.pdf

Wound care

Page 17 of 21


Complex wound management: Referral to

HITH at SCGH

Aim

To provide appropriate and timely referral to the HITH programme at SCGH for

women requiring complex wound management.

Key points

1. This service is only available to women who have a complex wound and meet

the criteria for referral.

2. Women may only be referred as outpatients. If hospitalisation is required they

shall remain at KEMH.

3. All issues identified by SCGH shall be communicated to KEMH medical staff at

Registrar level or above.

4. All women shall have a wound review at KEMH monthly while receiving

treatment through HITH at SCGH. SCGH will fax a referral to 6458 1031 for the

outpatient’s appointment.

5. Once care is complete SCGH will inform KEMH of the outcome by fax to 6458

1031.

Criteria for referral

Complex wound

Unsuitable for Silver Chain referral

Ambulant

Have transportation to and from SCGH at least 2 times per week.

Weight limits of

Maximum 180kg for a bed

Maximum 300kg for a chair

Process for referral

The patient is identified as suitable for referral

KEMH staff contacts the HITH LAN nurse on 6457 4838 to discuss the

management.

KEMH staff to commence a referral and wound care plan.

Fax the referral and wound care plan to 6457 2880

SCGH will contact the patient and inform her of the appointment details.

http://www.kemh.health.wa.gov.au/~/media/Files/Hospitals/WNHS/For%20health%20professionals/Clinical%20guidelines/OG/WNHS.OG.ReferraltoSilverChain.pdf

Wound care

Page 18 of 21


Inpatient referral process

Does patient meet

Silver Chain Referral criteria?

https://www.silverchain.org.au/wa/

referrers/refer-a-patient-to-home-hospital/

Refer patient to

SILVER CHAIN

Wound to be reviewed by admitting

Medical Team

NPWT to be commenced by Ward staff

Wound has a significant dehiscence?

Yes No

Refer patient to

attend SCGH,

HOME LINK

Call Silver Chain

Liaison Nurse 9242

0347 and complete

“Referral/ Transfer”

form https://

www.silverchain.org.au/

wa/referrers/referral-

forms

Call Home Link Liaison Nurse:

6457 4838

and complete referral form

(found in Home Link file)

Send patient home with items

listed in Home Link file.

Patient requires RV by

admitting team

MONTHLY whilst

receiving NPWT.

Patient requires review

within a fortnight of

discharge.

Supply patient with a

replacement NPWT

dressing and canister on

discharge.

Wound care

Page 19 of 21


VMS referral process

Does patient meet

Silver Chain Referral criteria?

https://www.silverchain.org.au/wa/

referrers/refer-a-patient-to-home-hospital/

Refer patient to

SILVER CHAIN

Patient to attend EC to be reviewed by

patient’s original admitting Medical Team

NPWT to be commenced by Emergency

Centre staff

Patient’s abdominal wound has a

significant dehiscence

Yes No

Refer patient to

attend SCGH,

HOME LINK

Call Silver Chain

Liaison Nurse 9242

0347 and complete

“Referral/ Transfer”

form https://

www.silverchain.org.au/

wa/referrers/referral-

forms

Call Home Link Liaison Nurse:

6457 4838

and complete referral form

(found in Home Link file)

Send patient home with items

listed in Home Link file.

Patient requires RV by

admitting team

MONTHLY whilst

receiving NPWT.

Patient requires review

within a fortnight of

discharge.

Supply patient with a

replacement NPWT

dressing and canister on

discharge.

Wound care

Page 20 of 21


References

1. Durai R, Movwnah A, Ng PCH. Use of drains in surgery: A review. The Journal of Perioperative Practice. 2009;19(6):180-6.

2. Sir Charles Gairdner Hospital. Wound drain management: Nursing Practice Guideline No. 652014. Available from: http://chips.qe2.health.wa.gov.au/NPG/pdf/Wound%20Drains%20(65).pdf.

3. Walker J. Patient preparation for safe removal of surgical drains. Nursing Standard. 2007;21(49):39-41.

4. Hickson E, Harris, J., & Brett, D. A journey to zero: Reduction of post-operative cesarean surgical site infections over a five-year period. Surgical Infections. 2015;16(2):174-7.

5. Stannard J, Atkins, B., O'Malley, D., Singh, H., Bernstein, B., & Fahey, M. et al. Use of Negative Pressure Therapy on Closed Surgical Incisions: A Case Series. Ostomy Wound Management. 2009;55(8):58-66.

6. Bullough L, Wilkinson, D., Burns, S., & Wan, L. Changing wound care protocols to reduce postoperative caesarean section infection and readmission. Wounds UK. 2014;10(1):84-9.

7. Smith and Nephew. Negative Pressure Wound Therapy Clinical Guidelines. 2013.

8. Cheng K LJ, Kong Q, Wang C, Ye N, Xia G. Risk factors for surgical site infection in a teaching hospital: a prospective study of 1,138 patients. Patient preference and adherence. 2015;9:1171-7.

9. Lindholm CS, R. Wound management for the 21st century: combining effectiveness and efficiency. International Wound Journal. 2016;13:5-15.

10. Healthcare Infection Surveillance Western Australia. Surveillance Manual. Government of Western Australia. 2014.

11. Australian Wound Management Association Inc. Standards for wound management. 2016. 3rd ed. Available from: http://www.woundsaustralia.com.au/home/.

Resources

SCGH Nursing Practice Guidelines:

No 16 Wound Management

No 65 Wound Drain Management

Silver Chain: Referrals Criteria & Referral Forms

World Health Organization (WHO): Global Guidelines for the Prevention of Surgical Site Infection (2016)

Related WNHS policies, procedures and guidelines

KEMH Clinical Guidelines:

O&G: Referral to Silver Chain

Infection Prevention and Management Manual: Hand Hygiene ; Prevention of Surgical Site Infections ; Aseptic Technique

http://chips.qe2.health.wa.gov.au/NPG/pdf/Wound%20Drains%20(65).pdfhttp://www.woundsaustralia.com.au/home/https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/SCGH/SCGH.NPG.Wound_Management.pdfhttps://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/SCGH/SCGH.NPG.Wound_Drain_Management.pdfhttps://www.silverchain.org.au/wa/referrers/refer-a-patient-to-home-hospital/https://www.silverchain.org.au/wa/referrers/referral-forms/https://apps.who.int/iris/bitstream/handle/10665/250680/9789241549882-eng.pdf?sequence=8https://apps.who.int/iris/bitstream/handle/10665/250680/9789241549882-eng.pdf?sequence=8http://www.kemh.health.wa.gov.au/~/media/Files/Hospitals/WNHS/For%20health%20professionals/Clinical%20guidelines/OG/WNHS.OG.ReferraltoSilverChain.pdfhttps://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/WNHS/WNHS.IC.HAI.HandHygiene.pdfhttps://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/WNHS/WNHS.IC.HAI.SSIs.pdfhttps://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/WNHS/WNHS.IC.HAI.SSIs.pdfhttps://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/WNHS/WNHS.IC.HAI.AsepticTechnique.pdf

Wound care

Page 21 of 21


File path: WNHS.OG.WoundCare

Keywords: wounds, wound drain, wound healing, closed drain, open drain, drain, vacuum drain, free drainage, replacing, changing a drain, drainage tube, shortening drain, T-Tube, vaginal drain, wound care, Topical negative pressure therapy, complex referral, Silver Chain, HITH

Document owner: Obstetrics & Gynaecology Directorate

Author / Reviewer: Pod –CNC Gynaecology Ward 6 & CMC Obstetric Wards

Date first issued: July 2018 Version: 1.1

Last reviewed: (v1.1 Jan 2019- minor amendments- added link to IPM guideline for surgical site dressings, hyperlinks updated and brands for detergent wipes removed)

Next review date: July 2021

Supersedes: Supersedes:

1. Wound Care (V1.0 dated July 2018)

History: July 2018 Amalgamated 12 individual wound & drain care guidelines from O&G (11 from wound/drain care & 1 wound swab guideline, dated from April 2001) into one document

Endorsed by: GSMSC Date: 05/07/2018

MSMSC Date: 24/07/2018

National Standards Applicable (V2):

1 Governance, 3 Preventing and Controlling Infection, 5 Comprehensive

Care (incl ), 6 Communicating (incl ), 8 Recognising & Responding to Acute Deterioration

Printed or personally saved electronic copies of this document are considered uncontrolled.

Access the current version from the WNHS website.

Related forms used at KEMH for recording wound and drain care:

Risk assessment for Pressure Ulcers (MR 260.01)

Comprehensive Skin Assessment (MR 260.03)

Wound Assessment and Care Plan (MR263)

Caesarean Birth Clinical Pathway (MR 249.61)

Gynaecology Nursing Observation Chart (MR 286)

Caesarean Section (MR 310) or Operation Record (MR 315)

Handover to Recovery/Ward (MR 325)

Fluid Balance Chart (MR 729)

Integrated Progress Notes (MR 250)

VMS to EC referral form (MR026)

VMS progress notes (MR255)

CLINICAL PRACTICE GUIDELINE Wound care...Wound care Page 2 of 21 Obstetrics & Gynaecology See SCGH...

Documents

Transcript of CLINICAL PRACTICE GUIDELINE Wound care...Wound care Page 2 of 21 Obstetrics & Gynaecology See SCGH...